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Surgery - Handbook 2010 - 2011
Annual Didactic Schedule 2010 - 2011
Knowledge and Life-Long Learning
(BSOM 1) By the conclusion of the surgery clerkship, the student will demonstrate the ability to:
- Organize clinical data from history and physical examinations and formulate diagnoses consistent with patient demographics such as age, gender and occupation.
- Develop complete surgical differential diagnoses based upon History and Physical and collated with other available data.
Prioritize laboratory and radiographic examinations to confirm or establish a diagnosis considering:
• Sensitivity and specificity of the tests that are ordered
• Associated risks
• Reliability and accuracy
• Cost effectiveness - Integrate basic science knowledge into patient problem solving
Recognize these surgical problems:
a. Emergent conditions:
• Acute abdomen
• Blunt trauma
• Penetrating trauma
b. Congenital conditions:
• Herniae
• Branchial cleft diseases
c. Acquired conditions:
• Volvulus-
• Diverticulosis
• Portal hypertension
• Hernia
d. Inflammatory conditions
• Appendicitis
• Cholecystitis
• Diverticulaitis
e. Neoplastic Disorders
• Breast cancer
• Pancreatic cancer
• Colon cancer - Describe evidence-based treatments for each of the above disorders
(BSOM1- SKILLS) By the conclusion of the Surgery Clerkship the student will have demonstrated competency in the following procedures mostly through patient care, but may include simulators:
- Venipuncture techniques
- Blood gas sampling
- Placement of arterial and venous lines
- Endotracheal intubation
- Urinary bladder catheterization
- Stomal dressing changes
- Assessing ankle brachial index
- Nasogastric intubation
- Wound dressing changes
- Suturing simple lacerations
- Use of local anesthetic agents
In addition the student will have familiarity with other procedures including the indications and possible complications of these procedures having viewed training videos or through the use of simulators:
- Chest tube placement
- Pericardiocentesis
- Abdominal Paracentesis
- Thoracentesis
- Cricothyrotomy
- Replace PEG tube
(BSOM 2) By the conclusion of the surgery clerkship, the student will demonstrate the ability to develop and present plausible theories about the causes and courses of patients' surgical illnesses and trauma in regard to:
- biological factors
- psychological factors
- social factors
- cultural factors
- economic factors
- high risk behavior
Interpersonal and Communication
(BSOM 4) By the conclusion of the surgery clerkship, the student will demonstrate the ability acquire data relative to developing surgical diagnoses by:
- Establishing rapport with patients by properly introducing self and defining the role the student will have in patients' care
- Being empathic with patients, showing genuine concern for patients' anxieties or concerns through tone of voice, style of speaking, facial expressions and gestures
- Facilitating data collection with helpful blends of open and closed questions
- Using language and behaviors that are sensitive to and accepting of differences in patients' age, gender, ethnicity, religion, and sexual orientation.
- Concluding interviews with proper timing and respect
(BSOM 4) By the conclusion of the surgery clerkship, the student will demonstrate the ability to elicit data for a complete surgical history, including:
- Chief complaints in patients' own words
Details for thorough histories of present surgical illness:
• Onset of symptoms
• Duration of symptoms
• Time lines of exacerbations and decreases of symptoms
• Presence of pain radiation
• Character of pain
• Level of pain on scale of 1 to 10.
• Association of systemic symptoms - Details for past general medical and surgical history
- Details for complete reviews of systems
- Details for family history
- Details for social history, including pertinent elements on gender, culture, ethnicity, and spirituality
(BSOM 4) By the end of the surgery clerkship the student will be able to perform a comprehensive physical examination having been graded by observing preceptor before doing independent assessments.
(BSOM 4) By the conclusion of the surgery clerkship, the student will demonstrate:
- Ability to develop a treatment plan
- Recognize contraindications for specific operative treatments in specific patients
- Inform patients about risks and benefits of surgical treatments
(BSOM 4) By the conclusion of the surgery clerkship, the student will demonstrate ability to present coherent, thoughtful presentations of surgery patients in both oral and written forms:
- History of present illness
- Past medical history
- Review of systems,
- Family and social history
- Physical examination differential diagnoses
- Differential diagnoses
- Lab data
- Treatment plans
(BSOM 5) By the conclusion of the surgery clerkship, the student will have demonstrated the ability to effectively communicate with patients and their family. This includes successful completion an OSCE examination developed to learn the art of breaking bad news.
(BSOM 6) By the end of the surgery clerkship the student will have demonstrated the ability to respond appropriately to constructive feedback given throughout the rotation from both peers and supervisors and specifically at the midterm formative feedback session.
(BSOM 7) At the conclusion of the surgery clerkship the student will have:
- Demonstrated the ability to assess their individual strengths, weaknesses, physical and emotional health and be willing to seek and accept supervision and constructive feedback.
- Demonstrated the ability to interact with peers, supervisors and ancillary hospital personnel with appreciation for their roles in care of the patient.
- Promote harmonious relationships through respect for role other specialists and personnel bring to total patient care.
(BSOM 8) At the conclusion of the Surgery Clerkship the student will demonstrate professionalism through the ability to:
- Be punctual and attend required events
- Complete patient notes in a timely fashion with legible writing
- Maintain professional boundaries (physical, sexual, financial, and emotional) with patients
- Be truthful about medical data
- Be courteous to patients, patients' families, staff, colleagues, and other health professionals
- Maintain confidentiality regarding patient care
- Demonstrate respect, empathy, responsiveness, and concern regardless of the patient's problems, personal characteristics, sexual orientation, cultural or ethnic background
- Demonstrate integrity, responsibility and accountability in the care of assignedpatients
(BSOM 9) At the end of the Surgery Clerkship, the student will demonstrate scholarship in the form of contributing to a positive learning environment, collaborating with colleagues, and performing self-assessment and self-directed learning.
Week Number |
From |
Topics |
Week #1 |
Surgery Texts of Choice |
Week #2 |
Surgery Texts of Choice |
Week #3 |
Surgery Texts of Choice |
Required: |
Week #4 |
Surgery Texts of Choice |
2. Small Intestines |
Week #5 |
Surgery Texts of Choice |
Additional: |
Week #6 |
Surgery Texts of Choice |
Week #7 |
Essentials of Surgical Specialties |
Required:Orthopedic Surgery, Diseases of the Musculoskeletal System |
Week #8 |
Appleton & Lange 4th edition |
Additional: |
Daily activities and participation in Service activities such as rounds and operations will be directed by and coordinated with the Chief/Senior resident on the Service. Didactic sessions, Grand Rounds, M&M Conference and Attending rounds take precedence over other daily activities.
Each student will contact their Chief/Senior Resident for guidance on:
a. Selection of appropriate patients to work-up
b. Conference attendance
c. Attending schedules for times of rounds, clinics and office. -
Students will introduce themselves to their patients at the first opportunity, obtain a history and physical examination and complete a write-up within 24 hours of admission. In all the cases, the H&P must be obtained before operation.
The write-up of the History and Physical exam should contain all facts pertinent to each of the patient's problems, including pertinent negatives. H&P's should be forwarded via e-mail to the clerkship director/coordinator at email@example.com within 48 hours of the patient encounter.
Students should read about the disease or the complaint the patient presents in one of the standard surgery texts or in a reference suggested by the preceptor or resident, with emphasis on differential diagnosis, not treatment.
Students should enter each patient encounter into RMS; listing admitting diagnosis, date, operation, and hours scrubbed: www.new-innov.com
Students are required to attend clinics or office hours during the course of their rotation in order to complete the outpatient histories and physical examinations. A minimum of one to two 1/2 days per week should be spent in the office or clinic.
Students will make rounds on inpatients with their resident and his/her team. They will not spend on average more than eighty hours per week in required clinical and educational activities. In addition, they must have a full 24-hour period free from these activities each week and may not participate for longer than 30 consecutive hours at any time. Required activities include, but are not limited to, formal didactic teaching, hospital rounds and activities, out-patient clinic attendance, in-house call, and attendance at examinations.
A General Surgery night call schedule may be provided to you at GSH, KMC, VAMC and WPMC at the discretion of the respective Associate Program Directors. Students assigned to MVH may also be assigned General Surgery Call on their assigned service at the discretion of the Associate Program Directors. Call duties may be no more frequent than every fourth night, on average. Additionally, the clerkship administrator will prepare and distribute a Trauma/Acute Care Surgery (ACS) Call Schedule assigning each student to at least two Trauma/ACS calls at MVH during the 6 course of the eight weeks of general surgery clerkship. Trauma Call schedules will be coordinated with the respective liaison at each site prior to the start of the clerkship in order to minimize conflicting schedules and avoid consecutive days of call. Weekday call: runs from 7:00 p.m. to 7:00 a.m. the following morning. Weekend Day call: runs from 7:00 a.m. to 7:00 p.m. The oncoming shift receives the outgoing team report for the day shift at 6:00 a.m. Weekend Night call: runs from 7:00 p.m. to 7:00 a.m. the following morning. Report for night shift is at 6:30 p.m. Hand-off reports take place in the in the Emergency Trauma Center conference room. You are to be changed into scrubs and be present for report on time. You should check in with the appropriate senior resident on the Red/ACS service when your call begins.
In the Trauma Center students are under the supervision of the Trauma Chief Resident. Students check-in at the beginning of the shift and keep the Chief Resident informed of their location throughout the shift.
Students assigned to trauma call at MVH will sign a receipt for an ACCESS Badge, Parking Decal, and Trauma Pager. They are required to report to the Resident/Student Coordinator in MVH Medical Education office on the 7th Floor of the Main Hospital building between the hours of 7:30 a.m. and 4:00 p.m. on any normal work-day, prior to their scheduled call day, for: a. A meal ticket b. A copy of the MVH student handbook c. Computer orientation and assignment of a password d. Orientation to the resident/student lounges and recreational areas e. Location of student locker rooms and sleeping rooms
Students are required to return their pagers, MVH ACCESS badges, parking decals, and complete all RMS clerkship requirements by the end of the Clerkship and prior to taking their NBME exam.
The Chief/Senior resident on your assigned service is the coordinator of daily activities.
Give students an opportunity to examine patients preoperatively and guide them through important features.
Page the students to see emergencies, especially at night and on weekends. Students on call should accept assignment of new patients being admitted to any preceptor to whom they are assigned.
Assist and supervise students in completing their assigned skills list. Provide help in learning as many procedures as possible.
Students are expected on morning resident rounds Monday through Friday, and weekends ONLY when on call or as directed by the Chief Resident in accordance with the participation hours stated on page five. WSU holidays are optional.
Daily Attendance is mandatory; only emergency medical excuses will be accepted. Physician verification will be required for absences in excess of 24 hours. Absence for other emergencies must be approved by the Clerkship Director.
Students are required to be observed performing at least one complete History and Physical examination during their rotation.
Students are required to complete 3 H&P's during the rotation. These may be accomplished in clinics, inpatient units, or private offices. The students will then turn in each written work-up via e-mail to the Clerkship Director for assessment and overall grading.
Students are expected to attend the following:
a. Didactic sessions (Friday afternoons)
b. Grand Rounds (Wednesday 7-8am)
c. Case Presentation Sessions (Wednesday 8-9 am)
d. Quizzes, Exams, and Ethics/Palliative Care OSCE (during the 6th week)
e. Surgical M&M (Monday mornings) -
Night Call: Students are assigned General Surgery call no more frequent than every fourth night at the discretion of the Associate Program Director at their assigned sites. In addition, all students are assigned two Trauma/Acute Care Surgery calls at MVH during the 8-week surgery clerkship. The Clerkship Administrator will supply the Trauma/ACS call schedule to students during their clerkship orientation. The Trauma/ACS call schedule is coordinated with the liaison at each site in order to avoid scheduling conflicts and consecutive days of call. There will be no Thursday night student coverage so as not to interfere with the didactic program on Fridays.
PRECEPTORS:A preceptor is simply a teacher. All the faculty and residents are preceptors. Junior students will be assigned to services and not to individual surgeons. In this context, the chief or senior resident on each service will be responsible for coordinating the activities of residents and students. The senior resident needs to be sure that the students are included in morning and afternoon rounds, in discussions of patients, in planning of treatment and in operating room and clinic activities. In addition, teaching should take place both on the wards and in the operating rooms. In this context, teaching does not mean lecture. Teaching means simply talking to the other residents and students about what is going to be done, the rationale for that decision instead of alternatives, and maintaining a dialogue during professional activities.
Each student will be assigned to a surgery service at their respective institution. This service will be lead by a chief/senior resident and may contain other residents, other students, and one or more attending surgeons. The chief resident is the person responsible for coordinating the activities of all the residents and students. Please develop rapport with this resident who will direct morning and afternoon rounds, decide who will participate in various operations, and direct other residents and students to various outpatient clinics.
As noted elsewhere, each student needs to complete a minimum of three admission work-ups during their clerkship. These work-ups consist of complete history and physicals (H&P's). The student should present each of these required three work-ups to either an attending surgeon or the chief resident on the service. Make every attempt that at least one presentation will be given to the assigned faculty preceptor.
Students are also required to be observed performing a complete History and Physical Examination. These may be performed in either the inpatient or outpatient setting.
It is important both for education and evaluation that the students seek out sufficient encounters with faculty, both in clinics and in the operating rooms. The chief resident can serve to direct and provide guidance, but the student may also exert initiative by looking at the operating room and clinic schedules and requesting the opportunity for attendance at specific operations or clinics from the chief resident.
Background While students must learn that high quality patient care requires personal sacrifice including at times, loss of regular sleep patterns, erratic meal times, and absence from customary social events and personal recreation, they must strive to discover compensatory strategies to maintain physical and mental health, as well as appropriate social and personal relationships. Therefore, to protect medical students from excessive fatigue that may impair functioning, the following policy has been adopted.SUMMARY OF POLICY: See below for more specific details
• Students will be on duty no more than an average of 80 hours per week
• Students will not spend more than 30 consecutive hours on duty
• Students will receive an average of 1 day in 7 free from all scheduled responsibilities
• Students will not be required to take overnight call 2 evenings prior to the Shelf examPolicy
Medical students engaged in clinical activity will be on duty no more than 80 hours per week (averaged over a four week period). For the purposes of this policy, "duty" hours are defined as time spent in the hospital or clinics directly related to patient care and on-call time (even if spent sleeping). Preparation for patient care and educational requirements, such as in-hospital conferences, required didactic sessions or exams are not considered "duty" time and may be done outside of the clinical settings.
Medical students shall not spend beyond 30 consecutive hours in the clinical setting while on duty. This allows students to remain in the hospital post-call for a few hours in order to complete on-call notes, patient care, and for the educational experience related to their on-call activities that may take place during the morning post-call.
Medical students will be provided with an average of 1 day in 7 free from all educational and clinical responsibilities, averaged over a 4-week period, inclusive of call. One day is defined as one continuous 24-hour period free from all clinical and educational activities.
4 Medical Students will not be required to take overnight "call" two evenings prior to their Shelf exam.
5 Student assignment for 24-hour "call" experiences should be scheduled based on student learning requirements and never on any service needs of the institution. 10
Students must be instructed on the signs and consequences of sleep impairment and emotional fatigue.
Students must have adequate sleeping facilities at every teaching site in which 24-hour call activities occur. These facilities must be available to the student 24 hours a day.
If a student feels that she/he may be at risk when operating a motor vehicle because of fatigue or sleep deprivation, they should obtain sleep at the on site call room before departing the premises or ask someone to take them home.
Faculty (and residents) should monitor students for symptoms and signs suggestive of impairment (including learning impairment) due to sleep deprivation and/or emotional fatigue. The faculty must advise the student appropriately if such observations are confirmed.
Faculty must notify the Clerkship Director of any student who suffers continued, persistent signs of sleep deprivation or emotional fatigue. If the situation persists, then faculty must notify the Associate Dean of Student Affairs.
Students should notify the Associate Dean of Student Affairs if they feel their learning is impaired due to sleep deprivation or emotional fatigue.
Students should notify the appropriate faculty attending, Clerkship Director or his/her designee
Prior to starting the M3 year, all medical students must sign an attestation statement indicating that they have read and understand this policy and will abide by its standards. The attestation statement should be turned in to the Office of Student Affairs no later than the first day of the M3 year.
Prior to starting the M3 year, all medical students must complete SAFER training (Sleep Alertness, and Fatigue Education in Residency). A printed certificate indicating that the student has successfully completed the training should be turned into the Office of Student Affairs no later than the first day of the M3 year.
All visiting students must follow
Clerkship Sites
Sites SpecificSITE SPECIFIC INFORMATION: MIAMI VALLEY HOSPITAL
Students will rotate on two of the three services at MVH, Gold, Green and Blue. Generally there are 3 third year medical students on each service. Each service has a Chief/Senior Resident, one or more junior residents, and occasionally a senior medical student. The Chief/Senior Resident is responsible for coordinating Resident and Medical Student activities and balancing service needs and educational opportunities. The student will function with this team, reporting to the Chief Resident for direction and determination of daily activities, consistent with other requirements such as conference attendance and preceptor encounters.
Parking: ACCESS Badges ar provided by the Clerkship Administrator to medical students during their General Surgery clerkship orientation. These badges may be used to gain entry to Parking Garages #2 & #3, entry to the OR suite, and the physicians' lounges. MVH Security is provided with a list of names and dates of students for monitoring. Students doing night/weekend call are authorized to park in the designated garages. Students attending General Surgery clerkship orientation at MVH can park free of charge in the Employees parking lot in the Fairgrounds ONLY (Entrance on Apple Street) or pay to park in the visitor's garage. NO PARKING PASSES WILL BE GIVEN to students. Meals: free meals with a $5 limit (1 per day) for medical students doing their General Surgery clerkship rotation or on call at MVH. Meal cards are issued to students by MVH Medical Education Department, on the 7th Floor of the Main Hospital during the hours of 7:30am and 4:00pm, at any time during their rotation (Meal passes cannot be used in Magnolia Place). Students doing night call are also authorized a meal card that can be used only on night call. WRIGHT STATE SURGEON'S CLINICS AT MVH
Parking: passes are given to medical students assigned to KMC for parking in designated parking areas. Passes will be given to students on the first day of their General Surgery rotation. Students attending conferences/classes at KMC can park free in the Church Lot across from KMC or pay to park in the visitor's garage. NO PARKING PASSES WILL BE GIVEN to students attending conferences/classes at KMC. Meals: free meals (2 per day) for medical students assigned to KMC for their General Surgery rotation. Meal cards will be given to students on the first day of their rotation. SURGERY CLINICS AT KMC
Douglas Paul, M.D. Parking: Students rotating or attending conferences/classes at GSH may park in the employees' surface lot at the corner of Philadelphia and Salem Avenue free of charge. Meals: free meals in the cafeteria for medical students assigned to GSH for their General Surgery rotation SURGERY CLINICS AT GSH
**Please note this schedule may change – check with the liaison secretary at your site for accuracy** |
Surgery Curriculum
The four basic components of the clerkship are:
1) An eight-week general surgery rotation
2) An eight-week surgical didactic curriculum
3) Trauma/Acute Care Surgery experience
4) An Ethics/Palliative Care OSCE
Each junior medical student will be part of what is called a service. The service is led by a chief or senior resident and may have other residents and other students as well as one or more surgery attendings. The chief resident is responsible for coordinating the service activities and this is the point person for the student. The chief/senior resident will organize and plan morning and afternoon rounds and participation by other residents and by medical students in various operative procedures and outpatient clinics. Students are encouraged to seek out clinical experiences and to discuss with the chief resident the benefits of various alternative activities. We believe that exposure to traumatized patients and those patients requiring immediate surgical intervention are valuable for all students. Accordingly, all students will have some on-call experience at MVH on the Trauma and/or Acute Care Surgery service so that this experience can be obtained. Students will also be assigned an attending who will act as a specific preceptor. Students are not restricted to this attending alone but are expected to establish contact with the preceptor and use them as a resource for instruction and direction during the clerkship.
Educational Objectives
- Obtain exposure to a broad range of surgical patients, problems and procedures
- Develop skills in physical examination, differential diagnosis and technical procedures
- Acquire a core surgical knowledge
- Demonstrate professional attitudes and behavior
- Learn to perform a problem-focused physical examination
- Develop a working diagnosis and initiate a diagnostic or therapeutic strategy
- Formulate a differential diagnosis for common outpatient surgical encounters
- Demonstrate the ability to perform a brief oral presentation of findings and assessment at the time of the encounter
- Prepare a brief discussion which includes a chief complaint, suspected diagnosis, data that supports your decision, a differential diagnosis, and diagnostic and therapeutic options as well as patient education and follow-up plans.
- Obtain exposure to patients potentially needing expeditious surgical intervention.
- Learn to identify, diagnose, resuscitate and develop operative and non-operative surgical treatment plans for acutely injured surgical patients.
- Exposure to traumatized patients
- Learn to evaluate, resuscitate and develop treatment strategies for injured patients
Quantified number and type of Surgery Cases that medical students are expected to encounter during their General Surgery Clerkship Experience
Type of Condition/Number |
Level of Participation |
Actual/Simulation |
Abdominal Surgery (Open): 1 case
Abdominal Surgery (Lap): 1 case
- See patients on units/clinics |
- Actual patients |
Breast Surgery: 2 cases
- See patients on units/clinics |
- Actual patients |
Vascular Surgery: 1 case
- See patients on units/clinics |
- Actual patients |
Trauma: 2 cases
- See patients in the MVH Trauma Center |
- Actual patients |
Skin Appendages: 2 cases
- See patients in the MVH Trauma Center or Clinics |
- Actual patients |
Thoracic Surgery: 1 case
- See patients on units/clinics |
- Actual patients |
The cases listed above represent the minimum exposure that students are expected to see during the general surgery clerkship rotation. Students may select the required number of cases from any listed in the respective groups and actively participate, to the degree indicated, as a member of the patients' management team.
When the number or types of patients on the service do not allow students to have adequate learning opportunities for any condition listed, students will be provided with a Virtual Patient experience for those conditions. These experiences consist of viewing case-based conditions on CD and completing the questions at the end of the presentation. Faculty discussion and interaction will be an active part of the presentations.
Each student will follow and write daily progress notes on patients he or she has admitted. A student will scrub from beginning to end of operations on the student's own patients' day or night.
DOCUMENTATION (of Clerkship Experience)
A. Procedure Logs:
Students are required to maintain a log of all procedures and skills encountered during the clerkship and record these experiences in the Residency Management Suite (RMS) Procedure Logs. The following information is required for each encounter: Patients' name, date of encounter, type of surgery (abdominal, bariatric, vascular, breast etc.), level of participation (observer, assistant, etc.), hours scrubbed, patient's status (inpatient/outpatient etc.), and name of preceptor, M.D. and status (attending or resident). These logs MUST be current by the last day of the clerkship before students are allowed to take the Shelf (NBME) Exam.
B. HISTORIES AND PHYSICALS (H&P's)
Each student must complete a minimum of 3 H&P's during the general surgery clerkship and submit their write-up via e-mail to the clerkship director for evaluation and grading. H&P's will be graded on format, content, and appropriateness of the differential diagnosis. These workups may be general surgery or subspecialty cases (excluding orthopedics) and should represent 3 different problems. Patients can be seen at any of the assigned sites during their rotation. At least one workup should be turned in during the first week of the rotation.
The Clerkship Director's Grade: The student will formally write up a brief patient encounter, differential diagnosis and discussion to be submitted to the clerkship director for evaluation and grading. Students are encouraged to complete their three write-ups in a timely fashion and turn them in to the clerkship coordinator in the WSUSOM DOS office. Word processing via computer will ensure legibility and timely feedback. The expectation is that students will learn to obtain a brief problem-oriented history, perform a focused exam, develop a differential diagnosis, read and briefly research the subject in order to prepare a short written discussion (example on page 16).
Each student is required to be observed performing one complete H&P during the course of the rotation. Once it is completed the student is required to record all pertinent information into RMS. As a minimum, the hospital site, Clinic or office, date of the exam, the patient's name, observer's name, and status (MD. or DO).
Students are required to keep an inventory and record in RMS the number of surgery procedures/skills exposures they have experienced during the course of the rotation. Examples of these encounters are:
- Drawing Venous Blood
- Drawing ABG's
- Starting IV
- NG Tube Placements
- Bladder Catheterizations
- Skin Suturing and Suture Removals
- Drain Removals
- Replacing/Removing Ostomy Devices
- Obtaining Cultures
The date, patients' name, type of procedures, preceptor, and the number of times performed will be recorded in the procedure logs in RMS prior to the last day of the clerkship and before being allowed to take the NBME exam.
DIDACTICS AND CONFERENCES (The first four are mandatory meetings)
Surgical Grand Rounds: Grand Rounds are held every Wednesday morning in the Dean Amphitheater at Kettering Medical Center from 7:00 to 8:00 a.m., September to June.
Case Presentation with the Department Chair: This meeting will take place at 8:00 a.m. on Wednesday mornings immediately following Grand Rounds. Students are to report to the designated meeting room in the Dining Room adjacent to the Dean Amphitheater at Kettering Medical Center at 8:00 a.m. When there is no Grand Rounds, Case Presentations will be conducted in the Department of Surgery Conference Room at 8:00 a.m. on Wednesday mornings.
Interactive Lectures. Reading assignments are listed on the Interactive Lecture and Additional Reading Schedules. All Assigned Readings are required reading and will be reflected on quiz and exam materials. Reading assignments are scheduled to distribute the material over the course of the 6 weeks.
Ethics/Palliative Care OSCE: Students are required to attend a 4-hour Ethics and Palliative Care OSCE during the course of the surgery clerkship. These are interactive sessions which are conducted by the faculty. Each student is evaluated and assigned a written grade for their performance.
Hospital Teaching Conferences: There are a variety of teaching conferences at each hospital and students are welcome at all of these. The chief/senior resident and the preceptor can be used as a guide to select which to attend.
H. Priorities: Interactive Lectures, Surgical Grand Rounds, M& M Conferences, and rounds with attending staff take precedence over all other activities for medical students except emergency operations on the student's own patients.
CC: Abdominal pain x 2 months. (Chief complaint and duration)
HPI: (All items re: PI including pertinent ROS and negatives. First
line- age, gender, race or ethnicity, parity, and occupation) The
patient is a 64 yo obese African American female nulliparous dental hygienist
who presents with a 2 month history of back and abdominal pain. The pain
is described as dull, constant, and a feeling of fullness in the abdomen. The
pain does not seem to have progressed over the past 2 months. Patient has
noticed some abdominal swelling. The pain is mostly localized to the RLQ of
the abdomen and the lower back in the midline. The pain does not radiate
and nothing seems to make it better. Patient has noted an approximately 10
pound weight loss over the last 2 months. Patient denies nausea, vomiting,
or a change in bowel habits. Patient also notes occasional leg cramps and
some occasional swelling. Patient notes occasional numbness and tingling in
the extremities, as well as joint stiffness. Patient denies fever, chills, or
night sweats. Patient also complains of occasional frequent urination. Her
PCP had ordered a CT scan which was suggestive of a retroperitoneal mass.
She is admitted for exploration and excision of the tumor.
PMH: Hypertension, Diabetes Mellitus type 2, and Asthma.
PSH: Partial Hysterectomy, for fibroids with metamenorrhagia
Social History: Patient is single, denies tobacco or drug use, and drinks
alcohol rarely.
Family History: One aunt with type 2 diabetes, a brother with colon cancer,
two aunts with breast cancer, and a maternal cousin with breast and ovarian
Allergies: Penicillin manifested as rash, but no hx of anaphylaxis.
Medications: Norvasc 500 mg daily, Lasix 40 mg daily, Flonase inh prn,
Advair inh 250 mcg daily, Spiriva inh prn, Metformin 100 mg daily, Albuterol
inh prn.
Vital Signs: BP 120/80, Pulse 70
General: Awake, Alert, NAD, Alert and Oriented x 3
HEENT: PERRLA, EOMI, Mucous membranes moist
Neck: Supple, no lymphadenopathy, smooth thyroid
Heart: RRR, no murmurs, no JVD
Lungs: CTA bilaterally, no wheezing or retractions
Abdomen: Soft and non-distended with a palpable mass on the right side
that measures approximately 15 x 20 cm by palpation. The mass is not very
mobile. The right side of the abdomen is mildly tender and the left side is
non-tender. Bowel sounds are audible.
Extremities: Radial pulses 2+ bilaterally. dorsalis pedis pulse 2+
Pelvic: patient refused.
Rectum: patient refused.
Differential Diagnosis:
1. Retroperitoneal tumor, etiology undetermined
1. Sarcoma (such as liposarcoma or leiomyosarcoma)
2. Lymphoma
3. Tumor of a retroperitoneal organ (ie – kidney, duodenum)
4. Germ cell tumor
The patient presented with nonspecific dull abdominal pain and a palpable
mass (which was very large, approximately 15 x 20 cm). Given the large
size of this mass, the most realistic next step is to immediately get a CT scan
to determine the location and involvement of internal organs. As I wrote in
the H&P, at the time we saw this patient, we already had a CT scan and a
biopsy showing that she had a retroperitoneal sarcoma, most consistent with
leiomyosarcoma. Given diagnosis of sarcoma, proceed with surgery to excise
the mass. The ideal margins for a sarcoma removal are >2cm. Given the
large size of this mass, the resection may have to include internal organs.
Neoadjuvant and/or adjuvant chemotherapy and radiation for retroperitoneal
sarcomas is being studied, but there is no evidence to warrant the use of
either in our patient.
Retroperitoneal sarcomas are dangerous because they can get quite large
without being noticed (especially in an obese patient). These sarcomas do
not have systemic effects until they compress other structures in the
abdomen. If you obtain a CT that demonstrates a retroperitoneal mass that
does not arise from an internal organ (ie- kidney, duodenum), your
differential needs to include a retroperitoneal sarcoma, lymphoma, germ cell
tumor, or testicular cancer. Therefore, it is very important to ask about
fevers and night sweats/chills to help identify lymphoma. The likely next
step is a biopsy of the mass. If the mass is <3 cm, you should do an
excisional biopsy. If it is >3 cm, an incisional biopsy is the method of choice.
In our case, an incsional core biopsy was done, confirming a retroperitoneal
sarcoma (leiomyosarcoma).
Once you have a diagnosis of a retroperitoneal sarcoma, it is important to
know that the only potentially curative treatment is complete surgical
resection. Retroperitoneal sarcomas tend to have a poor prognosis due to
their large size at diagnosis and therefore it is anatomically difficult to get 2
cm clear margins on resection. Not having 2 cm clear margins leads to a
greater likelihood of recurrence. It is also important to check for metastases
with sarcomas as they typically spread hematogenously to the lungs. Of
note, retroperitoneal sarcomas more commonly metastasize to the liver.
In conclusion, retroperitoneal sarcomas are difficult to catch early because
they have few effects until they exert pressure on other organs. This
underscores the importance of doing comprehensive abdominal exams on
each patient in the primary care setting.
Students are evaluated by interns, residents, and attendings on their assigned services. These evaluations are then put into a composite form by the Clerkship Administrator and used as the basis for the Clerkship Director's Summative evaluation which is submitted to student affairs.
Students are required to evaluate the clerkship in several parameters in RMS
- Evaluation of the effectiveness of the orientation process
- Assessment of the performance of the instructors of the interactive lectures
- Assessment of the General Surgery Clerkship experience
- Evaluation of Resident Teaching
- Evaluation of Attending Teaching
In addition, students are asked to complete a ballot in RMS: Nominating a Resident and/or an Attending for the Outstanding Teaching Awards for their class
INFORMAL FEEDBACK: Students should ask for feedback on a regular and
ongoing basis in order to determine their level of progress, and identify areas of
strengths and weaknesses. Simple questions like "How am I doing" or "What can
I do better" may get interesting results.
A. Formative Feedback: Each student is provided formative feedback by the faculty near the midway point of their clinical rotation. It is documented, dated, and signed by the faculty member and the student involved. These sessions afford each student an opportunity and sufficient time to make improvements, if needed. (Appendix iii)
B. Summative Feedback: This is the final grade and summation of evaluations received by the clerkship director at the end of the student's clerkship. The original copy of the final grade report, in composite form, is maintained in the office of Student Affairs and is excerpted into the Dean's letter. A copy of all evaluations and final grade composite reports are available in the department of surgery for reviewed by students.
The evaluation process disperses grading into as many elements of the clerkship as possible to monitor the clerkship, as well as mitigate the impact of any one grade. The relative value of each element is listed below. Students are invited to examine their entire student record regularly and to return after completion of the clerkship to see their entire record.
Evaluation |
Final Grade |
Evaluation |
Evaluator |
Histories & Physicals |
5% |
3 Required H&P workups |
Clerkship Director |
Ethics and Palliative Care OSCE |
10% |
One 4-hour Block |
Associate Clerkship Director/Faculty |
Preceptor Evaluation |
25% |
Compilation of Resident & |
Attendings & Residents |
Quizzes |
15% |
2 Q three weeks |
Clerkship Director |
Grades are reported as both a numerical and letter grade to determine class rank. A=>90%, B= 80%-89%, C= 70%-79%, D= 65%-69%, F= <65%
COURSE FAILURE: There are three components determining failure
REQUIRED ITEMS- (Must be submitted before last day of Clerkship)
Skills Exposure recorded in RMS – without grade
Observed H&P: Encounter recorded in RMS - without grade
Quantified Number/Types of Surgical Encounters entered in RMS – complete without grade
NBME: The NBME Shelf Exam is considered the final exam for the Surgery Clerkship. A score of less than 50% constitutes a course failure, regardless of the composite grade described above. In order to pass, the exam must be retaken or the entire clerkship repeated at the discretion of the Clerkship Director.
COMPOSITE SCORE: (As tabulated by the formula above.)
Sixty five percent is a passing grade for the surgery clerkship. Less than 65% represents course failure and may necessitates repeating the entire clerkship.
There are several excellent Surgery Textbooks listed below; however, the assigned reading schedule is based on Sabiston's Textbook. Sabiston's has the benefit of being accessible online through the campus library and there is a Pocket Companion to Sabiston available in the Campus Bookstore. If you should chose an alternative textbook, simply read the chapter corresponding to the one listed on the assignment sheet.
- Surgery: Scientific Principles and Practices (3rd Ed.) Greenfield, L.J. (Ed.) (2001) Philadelphia, PA: Lippincott, Williams & Wilkins
- Schwartz's Principles and Practices (8th Ed.) Brunicardi, F.C., Andersen, D.K., Billiar, T.R., Dunn, D.L., Hunter, J.G., & Pollock, R.E., (Eds.) (2004) New York, NY: McGraw-Hill
- Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice (17th Ed.) Townsend, C.M., Beauchamp, R.D., Evers, B.M., & Matton, K.L. (Eds.) (2004). Philadelphia, PA: Elsevier Inc.
- To access Sabiston's textbook on-line go to www.libraries.wright.edu and click on DATABASES
- Click on M
- Click on MDCONSULT and connect to the database
- Click on OPEN GENERIC ACCOUNT
- Click on BOOKS
- Scroll down to SURGERY, GENERAL
- Click on TOWNSEND: SABISTON TEXTBOOK OF SURGERY
The Virtual Patient: A Self-directed Study Guide in Surgery is a case-based curriculum in general surgery. These virtual patients teach medical students the approach to clinical surgery problems and outline management of common surgical diseases. Students are requested to review all sections and complete all questions. It is recommended that each student complete 3-4 sections per week so that all surgical topics can be reviewed in a timely fashion during the surgical clerkship.
SO, YOU WANT TO BE A SURGEON A medical student's online guide to Finding and Matching with the best possible surgical residency may be found at www.facs.org/residencysearch/
PLASTIC SURGERY Essentials for Students: The Plastic Surgery Educational Foundation provides supplemental information excerpted from copies of "Plastic Surgery Essentials for Students" handbook to all third year medical students in the United States and Canada. Continually updated information about various procedures in plastic surgery and other medical information of use to medical students and physicians are readily accessible at: www.plasticsurgery.org
SKILLS INSTRUCTION: Go to www.nejm.org. for video demonstrations.
Formative Feedback Form |
Clinical Evaluation Form |
Sample Pattern
(The diagnoses listed on the attached answer sheet may be used once)
Download Sample (PDF)
16 yo female with RLQ pain who is 2 weeks post menses and afebrile.
23 yo female 5 days post menses presents with RLQ pain and T102.6F.
18 yo extremely thin male with hx of recurrent episodes of right lower quadrant abdominal pain
20 yo female with acute onset of RLQ pain, afebrile, normal CBC, neg. pregnancy test, mass in right adnexa.
14 yo male with recent episodes red blood in stool presents today with RLQ pain.
20 yo female with scant menses for 2 months presents with RLQ pain and shock.
25 yo basketball player presents with severe pain radiating from R flank to R testis after strenuous game.
40 yo female with fever, shaking chills, N&V, right costovertebral angle and abd pain.
16 yo male with acute onset L testicular pain, nausea, L testis higher than R.
18 yo male dull, continuous lumbar pain radiating to lower abdomen after an all night beer bust.
25 yo male with sudden onset of abd pain while moving a woodpile with urticaria of web space of right hand and board like rigidity of abd.
24 yo med student returned from 3rd world has wt loss, chronic cough, lethargy, weakness, pigmentation of skin and mucous membranes with epigastric and periumbilical continuous pain.
30 yo Greek immigrant with episodic excruciating abd pain preceded by headache with Temp of 105 F, arthralgias.
26 yo male with severe, episodic abd pain, peculiar taste in mouth, darkening of gum margin and abnormal peripheral smear.
50 yo male with history of hysterical behavior vs. psychosis has severe colicky, generalized abdominal pain radiating to chest and back after taking a barbiturate.
65 yo with previous abdominal complaints now presents with LLQ pain which was initially localized by now is severe, generalized with fever and leukocytosis.
19 yo with gradual onset of cramping periumbilical pain which has migrated to RLQ and is accompanied by nausea, vomiting, fecal tenesmus and leukocytosis.
24 yo med student returns from 3rd world country with hx of diarrhea while away but chief complaint now is RUQ pain, fever, sweats, weight loss and has RLQ mass with hepatomegaly.
40 yo obese, multiparous female with episodic RUQ pain precipitated by fatty foods.
70 yo patient with history of marked weight loss and anorexia because of episodic cramping epigastric pain lasting one to three hours after eating, is more severe after large meals.
15 yo black male with sudden onset of severe stabbing LUQ pain with a friction run heard over the spleen, anemia and leukocytosis.
82 yo male with long history of epigastric and back pain presents with sudden onset of abdominal pain in mid abdomen and low back with a pulsatile mid abdominal mass.
7 yo boy presents with abd pain of 4 hours duration associated with anorexia, nausea and on exam found to have severe pharyngitis with tender submandibular nodes as well as localized RLQ tenderness.
80 yo male with acute onset of diffuse sever abdominal pain with no known alleviation or aggravating circumstances and no associated GI symptoms has soft abd with normal bowel sounds. EKG shows atrial fibrillation.
Elderly gentleman with Argyll Robertson pupils and Charcot's joints presents with sudden onset of continuous epigastric pain with hyperactive abdominal reflexes and slight tenderness but no rigidity.
45 yo male presents with continuous pressing pain in epigastrium which radiates to back and neck who is diaphoretic, anxious and has nausea and vomiting but no abd tenderness or rigidity.
4 yo girl presents with prostration, chills, fever, tachypnea who had complained of sudden onset abd pain in both upper and lower quadrants and is found to be markedly distended, diffusely tender, with doughy feel to abd and marked leukocytosis and ultrasound show free fluid.
16 yo girl with past history of spotty "rash" on buttocks and lower extremities associated with recurrent joint pains, awakens at night with mid abdominal pain, anorexia and vomiting has tenderness on exam but no rigidity.
7-month-old infant who is recovering from a prolonged upper respiratory infection presents with colicky abdominal pain and is passing "currant jelly" stools.
19 yo male recovering from infectious mononucleosis develops abd pain, maximal in LUQ and radiates to left shoulder and complains of weakness and lightheadedness.
70 yo female with history of CHF is on treatment with digitalis when she develops diffuse abd pain which is initially colicky and then becomes continuous associated with vomiting, maroon stools and has diffuse tenderness and rebound.
80 yo female with completely negative medical and surgical history except for occasional episodes of RUQ pain presents with signs and symptoms of small bowel obstruction and found to have distended abdomen and no herniae on exam. X-rays show small bowel distention and air in biliary tree.
6-week-old first-born male presents with history of projectile vomiting of recently ingested feedings.
35 yo illegal immigrant presents with abdominal pain which is associated with fever, anemia and ascites and a chest x-ray shows cavitary apical lesions.
24 yo med student studying for step 2 develops midepigastric pain which was initially controlled with TUMS® buy now is severe, diffuse and radiates to both shoulders is found to have board-like rigid abdomen.
46 yo male with arachnodactyly, ectopia lentis and high arched palate presents with acute onset of moderate chest pain which then becomes severe abdominally and spread to the back; cold clammy legs, and gross hematuria with a soft abdomen.
80 yo institutionalized patient with marked abdominal distention, no BM for 3 days with a long hx of constipation in whom abd x-rays show distended colon in "coffee bean" configuration and a "birds beak" on BE.
35 yo female G2, P2, with 3 day history of RUQ pain associated with nausea and vomiting, low grade fever, positive Murphy's sign and leukocytosis had cholelithiasis diagnosed 3 years ago.
24 yo female in head on collision is found to have mediastinal widening, a left apical cap, the left mainstem bronchus is depressed and the NG tube is seen to deviate to the right.
65 yo male, poor informant, presents with a recent episode of hematemesis. On physical exam he is found to have a well healed abd scar from xiphoid to pubis and well healed ileo-femoral scars bilaterally.
18 yo female admitted to ED after MVA in which she was unrestrained driver. Squad reports bent steering column and patient has BP 90/70, pulse 120, distended neck veins and distant heart sounds.
42 yo red headed farmer presents with irregular bordered, hairless, elevated, pruritic, deeply pigmented, multi colored 0.6cm lesion on right shoulder which bleeds easily when scratched.
18 yo female with recent awareness of a 2cm dia freely movable smooth mass in left breast with no systemic or other local symptoms.
27 yo male presents with a massive UGI bleed after being in previous excellent health. The endoscopist sees a bleeding moderate sized vessel and the fundus of the stomach.
48 yo male with IDDM presents with one day history of scrotal irritation. Exam reveals a depressed 1cm-dia black eschar of the left scrotum.
18 yo male with recent history of unguis incarnatus notes pain and swelling with heat and redness of the ankle, with red streaking of lower leg.
28 yo female with recent onset of weight loss, loss of hair, heat intolerance and proptosis.
70 yo white female with pruritic, exfoliating areolar dermatitis, which has been unsuccessfully treated with steroid creams.
60 yo female with 40 packs a year smoking history presents with nasal stuffiness, feeling of fullness in face, and distended jugular veins in both standing and recumbent positions.
80 yo female presents with a chief complaint of increasing fatigue and lassitude. Routine work-up uncovers a hypochromic microcytic anemia.
Interactive Lectures
Preoperative Medical Evaluation of Surgical Patients
Describe the value of the preoperative history, physical examination, and selected diagnostic and screening tests.
Describe the important aspects of communication skills
Discuss the elements of a patient's history that are essential in the preoperative evaluation of surgical emergencies.
Describe (and perform) the medical history of a patient who is undergoing an elective procedure.
Discuss the assessment of pulmonary and cardiac risk.
Describe the assessment of coagulation status.
Discuss the effect of diabetes, hepatic dysfunction, adrenal insufficiency, and malnutrition on preoperative and post-operative management.
Perform a comprehensive physical examination.
Discuss the appropriate preoperative screening tests.
Document a concise history and physical examination as well as daily progress notes on a surgical patient.
Ethical Issues in Surgical Practice
Describe the components of informed consent, and explain how it is obtained from surgical patients.
Discuss the underlying principles of successful physician-patient communication.
List the types of advance directives used. Describe how physicians respond to advance directives and "do-not-resuscitate" orders.
Discuss the central goals of end-of-life care.
Define shock, and list the two primary mechanisms that may cause cellular malfunction consistent with shock.
List the etiologies of these primary mechanisms that are responsible for shock.
List the clinical information (i.e., history, physical examination, diagnostic tests, and hemodynamic parameters) that helps to determine which of the two primary mechanisms is the predominant cause of shock in an individual patient.
Describe the interrelation between the two primary mechanisms of shock as a cause of cellular injury.
Describe the general principles of management that diminish cellular injury from the primary mechanisms of shock.
Fluids and Electrolytes
Know the range of normal values of Na+, K+, HCO3-, and Cl- in serum, gastric aspirate, bile, and ileostomy aspirate.
Understand the contributions that extracellular, intracellular, and intravascular volume make to body weight.
List four hormones or substances that affect renal absorption and excretion of sodium and water.
Compare the physical findings or symptoms of dehydration in the young and the elderly.
Understand the methods of determining fluid balance.
Describe the typical 24-hour fluid and electrolyte needs in the postoperative patient who has no complications.
Explain the composition of electrolytes in normal saline, lactated Ringer's solution, and 5% dextrose in water.
Surgical Bleeding and Blood Replacement
Using a patient's physical examination and medical history, determine the likelihood and etiology of possible bleeding disorders.
Name the five major etiologic factors that may lead to bleeding disorders.
Describe the common laboratory tests that are used to assess coagulation status, and explain how these tests apply to the diagnosis of the conditions discussed in Objective 2.
Identify the acute etiologic factors that might be responsible for extensive bleeding in a patient who has received massive transfusions.
Name the conditions that might lead to disseminated intravascular coagulation (DIC).
Describe the recommended component replacement therapy for the etiologic categories named in Objective 2, as well as the definitive treatment for the underlying cause of each.
Describe the process of obtaining and transfusing blood, the symptoms of a transfusion reaction, and the diagnosis and appropriate management of the different types of transfusion reactions.
Outline the steps that must be followed to assess the patient who has multiple injuries.
Describe the principles and methods that are used in the initial resuscitation and definitive care phase of trauma management.
Define shock, discuss its pathophysiology, and outline the management of hemorrhagic shock.
Describe the pathophysiology and initial treatment of both immediately life-threatening and potentially life-threatening thoracic injuries.
Describe the diagnostic and therapeutic procedures that pertain to abdominal trauma, including the indications, contraindications, and limitations of peritoneal lavage.
Outline the initial management of the unconscious patient who has a traumatic injury, and discuss the complications that can develop after head injury.
Define Glasgow Coma Scale, and describe its point scale and its prediction of neurologic recovery.
Describe the therapeutic interventions that reverse or delay the consequences of increased intracranial pressure.
Outline the management of a patient with a suspected spine or spinal cord injury, including proper immobilization techniques.
List the types of extremity injuries, and prioritize their assessment and management.
Describe the issues involved in the transportation or transfer of injured patients.
a. Gather, and record data in a legible and organized format for a focused history and physical examination of the trauma patient.
b. Know and practice universal precautions, proper aseptic, gowning and gloving techniques.
c. Know the steps for proper placement of Foley catheters, cardiac monitoring leads, and defibrillation pads.
d. Demonstrate a level trauma support by assisting with the following: Airway Management Suctioning External cardiac compression Suturing Wound care Local anesthesia Blood draws, ABG's
e. Understand fluid and electrolyte replacement in the trauma patient.
f. Demonstrate knowledge of trauma management, primary and secondary surveys.
Wounds and Wound Healing
Define a wound, and describe the sequence and approximate time frame of the phases of wound healing.
Describe the three types of wound healing and the elements of each. Describe the phases of wound healing that are distinct to each type of wound.
Describe the essential elements and significance of granulation tissue.
Describe the clinical factors that decrease collagen synthesis and retard wound healing.
Describe the rationale for the uses of absorbable and nonabsorbable sutures.
Discuss the functions of a dressing.
Define clean, contaminated, and infected wounds, and describe the management of each type.
Abdominal Wall, Including Hernia
Know the relations of the layers of the abdominal wall and their pertinent reflections into the groin.
Define indirect inguinal hernia, direct inguinal hernia, and femoral hernia.
List the factors that predispose to the development of inguinal hernias.
Define and discuss the relative frequency of indirect, direct, and femoral hernias by age and sex.
Define incarcerated inguinal hernia, strangulated hernia, sliding hernia, and Richter's hernia.
Outline the principles of management for patients with groin hernias, including surgical treatments for repair and the indications for their use.
Discuss the appropriate use of prosthetic materials in hernia repair.
Discuss the embryology of an umbilical hernia.
Surgical Infections
List the factors that contribute to infection after a surgical procedure.
List the four classes of surgical wounds and the frequency with which each type becomes infected.
Describe the principles of prophylactic antibiotic use.
List the clinical variables that affect antibiotic sensitivity when compared with in vitro tests.
Describe the events that lead to antibiotic resistance in a surgical patient who has an infection.
Discuss four common hand infections, and describe the treatment of each.
List the clinical variables that contribute to foot infections in patients with diabetes.
Identify the most likely bacterial species encountered initially with infection from a dog bite, from acute cholecystitis, and from acute perforated appendicitis, and infection found 2 hours after a perforated duodenal ulcer.
List three viruses that pose an occupational hazard for surgeons, and discuss methods to protect against infection.
List the causes of postoperative fever, and discuss the diagnostic steps for evaluation.
Breast Disease
Categorize the risk factors for breast cancer into major and minor factors.
Provide the guidelines for routine screening mammography.
Describe the diagnostic workup and management for common benign breast conditions, including breast pain, cysts, fibroadenoma, nipple discharge, and breast abscess.
List the diagnostic modalities and describe their sequence in the workup of a patient with a breast mass or nipple discharge.
Describe the preoperative evaluation for a patient with breast cancer.
Provide the differential diagnosis of a breast lump in a woman in her 20s and in a woman in her 60s.
Describe how ductal cancer in situ differs from invasive breast cancer. Describe its role as a risk factor for invasive cancer.
Explain the rationale for breast conservation treatment as the preferred therapeutic option for most stage I and stage II breast cancers.
Describe the rationale for adjuvant therapy, radiation therapy, and hormonal therapy in the treatment of breast cancer.
Describe the expected survival and local recurrence rates after treatment for early breast cancer.
Surgical Endocrinology
Thyroid Gland
Discuss the evaluation and differential diagnosis of a patient with a thyroid nodule.
List the different types of carcinoma of the thyroid gland and their cell type of origin; discuss the appropriate therapeutic strategy for each.
Understand the major risk factors for carcinoma of the thyroid gland and the prognostic variables that dictate therapy.
Describe the symptoms of a patient with hyperthyroidism; discuss the differential diagnosis and treatment options.
Parathyroid Glands
Understand the role of the parathyroid glands in the physiology of calcium homeostasis.
List the causes, symptoms, and signs of hypercalcemia.
Know the difference between primary, secondary, and tertiary hyperparathyroidism.
Discuss the evaluation and differential diagnosis of a patient with hypercalcemia.
Understand the management of acute and severe hypercalcemia. 6. Describe the indications for surgery for hyperparathyroidism.
Describe the complications of parathyroid surgery.
Describe the clinical features of Cushing's syndrome and discuss how lesions in the pituitary, adrenal cortex, and extraadrenal sites are distinguished diagnostically.
Discuss the medical and surgical management of Cushing's syndrome in patients with adrenal adenoma, with a pituitary adenoma causing adrenal hyperplasia, and with adrenocorticotropic hormone (ACTH) - producing neoplasm.
Describe the pathology, clinical features, laboratory findings, workup, and management of a patient with primary aldosteronism.
Discuss pheochromocytoma, including its associated signs and symptoms, appropriate diagnostic workup, and treatment.
Discuss adrenal cortical carcinoma, including its presentation, signs and symptoms, diagnostic workup, and management.
Discuss the management and evaluation of an incidentally discovered adrenal mass.
Discuss the causes of adrenal insufficiency in the surgical setting as well as the associated clinical and laboratory findings,
Multiple Endocrine Neoplasia Syndromes
Describe the multiple endocrine Neoplasia syndromes and their surgical treatment.
Classify pancreatitis on the basis of the severity of injury to the organ.
List four etiologies of pancreatitis.
Describe the clinical presentation of a patient with acute pancreatitis, including indications for surgical intervention.
Discuss at least five potential early complications of acute pancreatitis.
Discuss the criteria that are used to predict the prognosis of acute pancreatitis.
Discuss four potential adverse outcomes of chronic pancreatitis as well as the surgical diagnostic approach, treatment options, and management.
Discuss the mechanism of pseudocyst formation with respect to the role of the duct, and list five symptoms and physical signs of pseudocysts.
Describe the diagnostic approach to a patient with a suspected pseudocyst, including the indications for and the sequence of tests.
Discuss the natural history of an untreated pancreatic pseudocyst as well as the medical and surgical treatment.
List four pancreatic neoplasms, and describe the pathology of each with reference to cell type and function.
Describe the symptoms, physical signs, laboratory findings, and diagnostic workup of a pancreatic mass on the basis of the location of the tumor.
Describe the surgical treatment of pancreatic neoplasms.
Discuss the long-term prognosis for pancreatic cancers on the basis of pathology and cell type.
Discuss the anatomy and functions of the spleen.
Discuss the workup and management of a patient with splenic injury.
Discuss the role of splenectomy in hematologic abnormalities.
Distinguish between splenomegaly and hypersplenism, and discuss their causes.
Discuss the consequences of splenectomy and the potential methods to reduce the associated risks.
Biliary Tract
Discuss the factors that contribute to the formation of the three most common types of gallstones.
Describe the epidemiology of gallstone disease as it relates to patient evaluation and management.
Discuss the most useful laboratory tests and radiologic studies to evaluate patients with diseases of the biliary tract.
Describe the management of asymptomatic gallstones found incidentally on radiologic studies or at celiotomy.
Compare and contrast the: (1) clinical presentation, (2) laboratory and radiologic findings, (3) management of a patient with chronic cholecystitis (biliary colic) and a patient with acute cholecystitis.
List the differences in the clinical presentation and evaluation of a jaundiced patient with choledocholithiasis and a jaundiced patient with biliary obstruction secondary to malignancy.
Describe the clinical presentation, evaluation, and management of a patient with: (1) acute cholangitis and (2) acute suppurative cholangitis. Highlight the differences between the two conditions.
Discuss the clinical presentation, evaluation, and management of a patient with acute (gallstone) pancreatitis.
Outline the clinical presentation, evaluation, and management of a patient with gallstone ileus. Contrast these with the corresponding features of other types of small bowel obstruction.
Discuss the epidemiology, clinical presentation, evaluation, and management of carcinoma of the gallbladder.
Outline the clinical presentation, evaluation, and management of carcinoma of the extrahepatic biliary ducts.
List the common causes of benign strictures of the common bile duct, and describe the clinical features of patients who have such strictures.
Discuss the various options available to treat stones in the gallbladder and the extrahepatic biliary ducts.
Outline the indications for laparoscopic cholecystectomy. Discuss the advantages of this approach over open cholecystectomy.
Compare and contrast the complications associated with laparoscopic cholecystectomy with those associated with open cholecystectomy.
Describe the postoperative management of a patient after: (1) cholecystectomy and (2) common bile duct exploration.
Colon, Rectum, and Anus
Diverticular Disease
- Describe the clinical findings of diverticular disease of the colon
- Discuss five complications of diverticular disease and their appropriate surgical management.
- List the differential diagnosis, initial management, diagnostic studies, and indications for medical versus surgical treatment in a patient with left lower quadrant pain.
Polyps and Carcinoma of the Colon, Rectum, and Anus
- Identify the common symptoms and signs of carcinoma of the colon, rectum, and anus.
- Discuss the appropriate laboratory, endoscopic, and x-ray studies for the diagnosis of carcinoma of the colon, rectum, and anus.
- Using the TNM and Dukes' classification systems, discuss the staging and 5-year survival rate of patients with carcinoma of the colon and rectum.
Ulcerative Colitis and Crohn's Disease of the Colon
- Differentiate ulcerative colitis from Crohn's disease of the colon in terms of history, pathology, x-ray findings, treatment, and risk of cancer.
- Discuss the role of surgery in the treatment of patients with ulcerative colitis and Crohn's colitis.
Colonic Obstruction and Volvulus
- List the signs, symptoms, and diagnostic aids for evaluating presumed large bowel obstruction.
- Discuss at least four causes of colonic obstruction in adults, including the frequency of each cause.
- Outline a plan for diagnostic studies, preoperative management, and treatment of volvulus, intussusception, impaction, and obstructing colon cancer.
- Given a patient with mechanical large or small bowel obstruction, discuss the potential complications if the treatment is inadequate.
- Discuss the anatomy of hemorrhoids, including the four grades encountered clinically, and differentiate internal from external hemorrhoids.
- Describe the symptoms and signs of patients with external and internal hemorrhoids.
- Outline the principles of management of patients with symptomatic external and internal hemorrhoids, including the roles of nonoperative and operative management.
Perianal Infections
- Outline the symptoms and physical findings of patients with perianal infections.
- Outline the principles of management of patients with perianal infections, including the role of antibiotics, incision and drainage, and primary fistulectomy.
Anal Fissures
- Describe the symptoms and physical findings of patients with anal fissures.
- Outline the principles of management of patients with anal fissures.
Anal Malignancy
- Name the two most common cancers of the anal canal and describe their clinical presentation.
- Describe the recent changes in the approach to the treatment of anal canal cancers.
Stomach and Duodenum
Small Intestine and Appendix
Diseases of the Vascular System
Arterial Disease: Atherosclerosis, Aneurysms, Peripheral Arterial Occlusive Disease, and Cerebrovascular Insufficiency
Venous Disease: Deep Vein Thrombosis and Pulmonary Embolus
Vasospastic Disorders, Vascular Trauma, and Lymphatic Disorders
Diagnostic Radiology in Vascular Disorders
Urology: Diseases of the Genitourinary System
Testes, Male Infertility, and Impotency
Cardiothoracic Surgery:
Cardiothoracic Surgery: Diseases of the Heart, Great Vessels, and Thoracic Cavity
Surgical Oncology
Malignant Diseases of the Skin
Malignant Diseases of the Lymphatics and Soft Tissue
List at least three common benign tumors of the liver, and describe their appropriate treatment.
List four factors that favorably influence the prognosis after resection of hepatic metastasis from colorectal cancer.
List the two most common primary hepatobiliary malignancies and their relative frequency.
List the steps involved in diagnosing a hepatic mass.
Compare and contrast the clinical and pathological features and the treatment of hepatic adenoma and focal nodular hyperplasia.
List the three major complications of portal hypertension.
List four forms of specific therapy for acute variceal hemorrhage in the order in which they are typically applied.
List at least three sites of portosystemic collateral formation in patients with portal hypertension
List at least four causes of portal hypertension.
List three complications associated with ascites formation in the patient with portal hypertension.
List four common indications for liver transplantation.
List three common causes of fulminant hepatic failure.
Describe the settings in which opportunistic bacterial, fungal, and viral infections occur after liver transplantation.
Compare and contrast the common symptoms and pathogenesis of gastric and duodenal ulcer disease, including patterns of acid secretion.
Discuss the significance of the anatomic location of gastric and duodenal ulcers.
Discuss the diagnostic value of upper gastrointestinal roentgenograms, endoscopy with biopsy, gastric analysis, serum gastrin levels, and the secretin stimulation test in patients with suspected peptic ulcer disease.
Describe in detail the nonoperative management of patients with peptic ulcer disease.
Discuss the complications of peptic ulcer disease, including the clinical presentation, diagnostic workup, and appropriate surgical treatment.
List the clinical and laboratory features that differentiate Zollinger-Ellison syndrome (gastrinoma) from duodenal ulcer disease.
Compare the risk of carcinoma in patients with gastric ulcer disease with the risk in those with duodenal ulcer disease.
Describe the common operations performed for duodenal and gastric ulcer disease, and discuss the morbidity rates associated with each procedure.
Discuss the commonly recognized side effects associated with surgery for duodenal and gastric ulcer disease.
Identify the premalignant conditions, epidemiologic factors, and clinical features in patients with gastric adenocarcinoma.
Describe the common types of neoplasms that occur in the stomach, and discuss the appropriate diagnostic procedures, therapeutic modalities, and prognosis for each.
List the general principles of curative and palliative surgical procedures for patients with a gastric neoplasm.
Discuss the signs, symptoms, and differential diagnosis of acute appendicitis, and describe how diseases that mimic it may be differentiated.
Outline the diagnostic workup of a patient with suspected appendicitis, and describe the laboratory findings that would confirm the diagnosis.
List and discuss the common complications of appendicitis and subsequent appendectomy, and explain how each would confirm the diagnosis.
Describe the presentation and management of appendiceal carcinoid and its significance as an incidental finding.
Discuss the location, frequency, size, and various clinical presentations of a patient with a Meckel's diverticulum.
Describe the treatment of Meckel's diverticulum that is incidentally found at surgery and the treatment of one that is symptomatic.
Describe the various clinical presentations of a patient with Crohn's disease, and explain how they can differ from the presentation of a patient with ulcerative colitis.
Outline a diagnostic approach to a patient with Crohn's disease.
Discuss the medical and surgical treatment plans for patients with Crohn's disease. Describe the complications associated with the disease process, and explain when surgery is indicated.
Discuss the relative frequency of the most common malignant and benign small bowel tumors.
Describe the carcinoid syndrome, and list the features of a carcinoid tumor that suggest it may be malignant. List the features that must be present for carcinoid syndrome to occur.
Discuss the clinical presentation and diagnostic approach to the following types of small bowel tumors: adenocarcinoma, carcinoid, and lymphoma.
Discuss the role of surgery in the management of patients with small bowel tumors.
Describe the common etiologies, signs, and symptoms of small intestinal mechanical obstruction, and contrast them with those of paralytic ileus.
Discuss the complications of small intestinal obstruction, including fluid and electrolyte shifts, vascular compromise of the small intestine, and sepsis.
Outline the appropriate laboratory tests and x-rays that are used in the diagnostic evaluation of a patient with a suspected small intestinal obstruction.
Discuss the clinical appearance of small bowel strangulation and the potential difficulty of making the diagnosis.
Compare and contrast mechanical small intestine obstruction with colon obstruction.
Outline a treatment plan for a patient with small intestinal obstruction. Discuss the indications for operative therapy.
List the classification of burns by depth of injury, and indicate the anatomic and pathophysiologic differences between these injuries.
List the initial steps in the acute care of the patient with a burn injury.
List three types of inhalation injury, and describe their pathophysiology.
List the general indications for referral of a patient to a burn center.
Define burn shock, and outline its treatment.
List the advantages and disadvantages of facial and tangential excision of burn wounds.
In addition to fluid resuscitation and surgery, list three other general areas of care that are important in the management of patients with burns.
Describe the five risk factors for the development of atherosclerosis.
List three specific sites that have a predilection for atherosclerotic plaque, and explain why this predilection exists.
List at least two clinical sequelae of atherosclerosis and three ways to retard the atherosclerotic process.
List the common sites and relative incidence of arterial aneurysms.
List the symptoms, signs, differential diagnosis, and diagnostic and management plans for a patient with a rupturing abdominal aortic aneurysm.
Discuss the indications, contraindications, and risk factors for surgery in patients with chronic abdominal aneurysms.
Define and discuss the prevention of the common complications of aneurysm surgery.
Compare the presentation, complications (i.e., frequency of dissection, rupture, thrombosis, and embolization), and treatment of thoracic, abdominal, femoral, and popliteal aneurysms.
Describe the pathophysiology of intermittent claudication, and differentiate this symptom from leg pain from other causes.
Describe the diagnostic approach and medical management of arterial occlusive disease. Discuss the roles of common noninvasive procedures.
List the criteria to help differentiate among venous, arterial, diabetic, and infectious leg ulcers.
Describe the operative treatment options available for chronic occlusive disease of the distal aorta and iliac arteries, superficial femoral and popliteal arteries, and tibial and peroneal arteries.
List four indications for amputation, and discuss the clinical and laboratory methods used to select the amputation site.
Describe the clinical manifestations, diagnostic workup, and surgical indications for chronic renal artery occlusion.
Describe the natural history and causes of acute arterial occlusion, and differentiate between embolic and thrombotic occlusion.
List six signs and symptoms of acute arterial occlusion, and outline its management (e.g., indications for medical vs surgical treatment).
Define and differentiate among the following:
A. Amaurosis fugax
B. Transient ischemic attacks
C. Reversible ischemic neurologic defect
D. Cerebrovascular accident (stroke) -
Outline the diagnostic methods and the medical and surgical management of a patient with symptomatic carotid artery disease.
List the differential diagnoses and outline a management and treatment plan for patients with transient ischemic attacks.
Differentiate between hemispheric and vertebrobasilar symptoms.
Identify the usual initial anatomic location of deep vein thrombosis, and discuss the clinical factors that lead to an increased incidence of this problem.
Identify the invasive and noninvasive testing procedures used to diagnose venous valvular incompetence and deep vein thrombosis.
Outline the differential diagnosis of acute edema associated with leg pain.
Describe five modalities to prevent the development of venous thrombosis in surgical patients.
Describe the methods used to administer anticoagulant and thrombolytic agents. Discuss how the adequacy of therapy is evaluated.
Describe the clinical syndrome of pulmonary embolus, and identify the order of priorities in diagnosing and caring for an acutely ill patient with life-threatening pulmonary embolus.
List the indications for surgical intervention in venous thrombosis and pulmonary embolus.
Outline the diagnostic, operative, and nonoperative management of venous ulcers and varicose veins.
List five underlying diseases or disorders associated with vasospastic changes in the extremities, and discuss their diagnosis and treatment.
Describe the anatomic mechanisms that cause thoracic outlet compression syndrome, and discuss the appropriate diagnostic studies and surgical treatment.
List the indications for arteriography in a patient with a possible arterial injury to the extremities.
In a patient with recent trauma, outline the physical findings, diagnostic plan, and treatment for suspected arterial injury.
Define lymphedema praecox, lymphedema tarda, primary lymphedema, and secondary lymphedema.
Explain the pathophysiology of lymphedema, and discuss its treatment.
Describe the indications and risks for arteriogram and venogram.
Define and discuss transluminal angioplasty, and cite the indications for this procedure.
Discuss the method, use, and reliability of perfusion and ventilation scans.
Define the anatomy and physiology of the prostate gland.
Compare the clinical presentation, workup, and management of a patient with acute prostatitis, a patient with chronic prostatitis, and a patient with nonbacterial prostatitis.
Define the clinical presentation, workup, and management of a patient with benign prostate hypertrophy.
Describe how clinical evaluation and diagnostic studies can help a practitioner to distinguish between benign prostatic hypertrophy, and prostate cancer.
Discuss the use of prostate-specific antigen determinations in evaluating patients with carcinoma of the prostate and benign prostatic hypertrophy.
Outline the staging and management of prostate cancer, both localized and advanced.
Discuss the types of renal trauma, the mechanisms involved, and the appropriate management of each.
Discuss two congenital urinary tract anomalies that require attention.
Discuss the etiology and management of inflammatory renal disease, and outline the treatment of pyelonephritis.
Describe the workup for a renal mass lesion. Discuss the characteristic findings in benign and malignant renal masses.
Describe the workup and treatment options in the management of patients with calculous disease of the urinary system.
Describe the etiology, clinical presentation, sequelae (if untreated), and management of ureteral obstruction.
Outline the management of iatrogenic ureteral injuries.
Describe the different tests used in an urodynamic evaluation.
Describe the pathophysiology of vesicoureteral reflux, its evaluation, and modes of treatment.
Discuss the evaluation and treatment of bladder trauma.
Describe the pathophysiology, diagnosis, and treatment of bacterial cystitis and interstitial cystitis.
Describe the symptoms, evaluation, and treatment of bladder fistulae.
Discuss the physiology of normal bladder function and disorders of micturition (e.g., incontinence, neurogenic bladder).
Discuss the etiology, presentation, and treatment of bladder cancer.
Describe the etiology, clinical presentation, evaluation, and management of penile trauma.
Describe the etiology, clinical presentation, evaluation, and treatment of penile cancer.
Describe the clinical presentation and management of four acquired penile disorders.
Describe the clinical presentation and management of three congenital penile anomalies.
Discuss six sexually transmitted diseases. Demonstrate knowledge of their causative pathogens, clinical presentation, evaluation, and treatment.
Discuss the indications for and complications of circumcision.
Describe the etiology, clinical presentation, evaluation, and management of urethral trauma.
Describe the natural history, evaluation, and treatment in male and female urethral cancer.
Discuss the etiology, presentation, evaluation, and management of urethral stricture disease.
Describe the clinical presentation, evaluation, and management of posterior urethral valves and hypospadias.
Name the common pathogens responsible for urethritis.
Discuss three congenital anomalies involving the testes.
Discuss the evaluation and differential diagnosis of the patient with acute testicular pain.
Describe three scrotal infections.
Describe the evaluation of a patient with a scrotal mass.
Discuss germ cell tumors of the testicle, their staging, and their treatment.
Provide a concise evaluation plan for the infertile male.
List the four major categories of erectile impotency.
Describe the anatomic and physiologic factors that predispose people to reflux esophagitis.
Describe the techniques for examining the esophagus.
Describe esophageal hiatal hernia with regard to anatomic type (sliding and paraesophageal) and the need for treatment.
Describe the symptoms of reflux esophagitis, and discuss the diagnostic procedures used to confirm diagnosis.
List the indications for operative management of esophageal reflux. Discuss the physiologic basis for the antireflux procedure used.
Describe the pathophysiology and clinical symptoms associated with achalasia of the esophagus. Briefly outline the management options.
Describe the radiologic findings that characterize motility disorders of the esophagus, including achalasia. Discuss manometric evaluation of the lower esophageal sphincter.
List the common esophageal diverticula in terms of their location, symptoms, and pathogenesis.
Differentiate the etiologic factors associated with pulsion and traction diverticula of the esophagus.
List the common types of benign esophageal neoplasms, and briefly describe how they are differentiated from malignant lesions.
List the two major cell types of esophageal neoplasms.
List the known etiologic factors for esophageal neoplasms.
List the symptoms that suggest esophageal malignancy.
Describe the natural history of a malignant lesion of the esophagus, and list the treatment options in order of preference.
Outline a plan for the diagnostic evaluation of a patient with a suspected esophageal tumor.
List the diagnostic modalities that are helpful in staging esophageal neoplasm.
Describe the etiology and presentation of traumatic perforation of the esophagus and the physical findings that occur early and late after this type of injury.
Assess a list of typical hemodynamic measurements (including central venous pressure, pulmonary arterial pressure, pulmonary artery wedge pressure, and cardiac output) in a normal patient and a patient with hypovolemic shock, cardiac tamponade, or acute myocardial infarction.
Discuss the advantages of, indications for, and possible complications of a central venous line versus a Swan-Ganz catheter.
List the risk factors and common clinical symptoms in a patient with ischemic heart disease, and discuss the differential diagnosis.
List treatment options for patients with ischemic heart disease.
Describe the indications for surgical intervention in a patient with ischemic heart disease, and evaluate the variety of techniques available, including minimally invasive approaches.
Describe the complications of a myocardial infarction.
Explain the physiologic benefits of intraaortic balloon pump counter pulsation as well as its complications and contraindications.
State the clinical indications for aortic, tricuspid, and metal valve replacement.
List the American Heart Association indications for prophylactic antibiotics in patients with heart disease.
Discuss the common congenital cardiac abnormalities, including patent ductus arteriosus, tetralogy of Fallot, coarctation of the aorta, septal defects, and transposition of the great vessels, and stratify these abnormalities according to cyanotic or acyanotic presentation.
Describe the appropriate management of acute cardiac tamponade.
List the indications for pacemaker insertion.
Discuss the unique contributions of extracorporeal circulation and myocardial preservation techniques to cardiac surgery.
Describe the evaluation and treatment of traumatic rupture of the aorta, and discuss the complications of treatment.
Describe the evaluation and treatment of aortic dissection.
Describe the clinical manifestation, anatomy, and treatment of thoracic aortic aneurysms.
Discuss the diagnostic modalities available to investigate chest lesions (e.g., pulmonary mass, chest wall tumor, pleural disease).
Discuss the evaluation and differential diagnosis of hemoptysis.
Create an algorithm to evaluate a solitary lung nodule.
Describe the common causes of pleural effusion, and discuss the distinction between exudates and transudate.
Discuss the etiology and management of lung abscess and empyema.
Define and discuss the management of various types of chest trauma, including open pneumothorax, tension pneumothorax, hemothorax, and flail chest.
Discuss the workup and management of patients with chest wall and mediastinal pathology.
Discuss the preoperative evaluation of patients for thoracic surgery.
Describe the common pathologic lesions of the anterior, posterior, and superior portions of the mediastinum.
Discuss the risk factors and symptoms of lung cancer.
Discuss the management of primary lung neoplasms.
Describe the preoperative and assessment of patients who undergo pulmonary resection.
List the most common sources of metastatic lesions in the lung, and discuss the management of metastatic disease in the chest.
List the organs and tissues that are currently being transplanted, and give the statistics for graft survival for organs from living related and cadaver organs.
List the criteria used to establish death for the purpose of organ and tissue donation.
Given a potential donor, list the acceptable and exclusionary criteria for the donation of each organ and tissue.
Describe the methods of organ preservation during the interval from harvest to transplantation for the kidney, liver, pancreas, heart, and lung. List the acceptable intervals for preservation.
Define autograft, isograft, allograft, xenograft, orthotopic graft, and heterotopic graft.
List the current forms of immunosuppression for transplantation, and describe their mechanisms of action and specific complications.
Distinguish among hyperacute, accelerated acute, acute, and chronic rejection in terms of pathophysiology, interval from transplant, histology, and prognosis.
List the common methods used to gain access to the circulation for hemodialysis.
Describe the etiology and incidence of basal and squamous cell carcinomas.
Discuss the clinical characteristics, treatment methods, and prognosis for basal and squamous cell carcinomas.
List the predisposing factors for and the four categories of melanoma.
List four signs and symptoms of a malignant nevus.
Outline the steps to confirm a diagnosis and determine the extent of a malignant nevus; describe the malignant potential and prognosis.
On the basis of the extent of a malignant nevus, describe the malignant potential and prognosis.
Outline the local, regional, and systemic therapies for malignant melanoma.
List the signs and symptoms of Hodgkin's disease and non-Hodgkin's lymphoma.
Describe the workup for a patient with biopsy-proven lymphoma.
Describe the role of the surgeon in the staging of Hodgkin's disease and non-Hodgkin's lymphoma.
List the clinical features of a sarcoma in the trunk or abdomen and in the extremity.
Describe the considerations in the evaluation of sarcoma, including the techniques, biopsy, and studies to localize and adequately stage the disease.
Discuss the treatment of sarcomas, including surgery, radiation therapy, and chemotherapy.
List at least four factors in a patient's medical history and physical examination that indicate malnutrition.
Discuss the following objective assessments of nutritional status: anthropometric measurements, biochemical blood tests, the urine urea nitrogen test, and indirect calorimetry.
Determine a patient's protein and calorie requirements by estimation, with the Harris-Benedict equation, or with specific laboratory tests.
List at least four water-soluble vitamins, three fat-soluble vitamins, and four trace elements that must be added to long-term parenteral nutrition.
Briefly describe the metabolic changes that occur in short-term and long-term starvation.
Discuss the effect of the injury or infection on a patient's metabolism, and describe how nutritional support must be altered.
List at least five indications each for enteral and parenteral nutritional support.
Discuss the factors involved in choosing a route of nutritional support.
Describe the risks and benefits of enteral and parenteral nutritional support.
List at least four gastrointestinal, four mechanical, and four metabolic complications of enteral therapy, and describe appropriate prevention or treatment of each.
List four adverse sequelae of a total parenteral nutrition (TPN) catheter and four metabolic complications of TPN. Describe the appropriate treatment of each.
Adrenal Glands
Palliative Care Education
18 Essential Topics in Adult Palliative and Hospice Care
© 2007 Medical College of Wisconsin
This contains 18 of the most requested educational topics in adult palliative and hospice care. Each presentation contains up-to-date information on key topics of interest for physicians caring for seriously ill and dying patients. The files are organized into 5 Sections; each Section contains 3 to 5 distinct modules covering specific topics (e.g., pain). Within this page are the following files:
- PowerPoint TM presentations for each individual module.
- Fast Facts and Concepts – Microsoft Word docs to be used as supplementary learning material to the PowerPoint presentations
- Multiple-choice Question Exams based on the PowerPoint presentations and the Fast Facts.
- An Evaluation form
Section |
Topic Title |
Fast Facts (PDF) |
Palliative Care |
#1 |
#2 |
#3 |
#4 |
#5 |
Questions |
Answers |
Evaluation |
Communication skills |
#6 |
#7 |
#8 |
Questions |
Answers |
Evaluation |
Pain |
#9 |
#10 |
#11 |
Questions |
Answers |
Evaluation |
Non-Pain Symptoms |
#12 |
#13 |
#14 |
#15 |
Questions |
Answers |
Evaluation |
Final Weeks of Life |
#16 |
#17 |
#18 |
Questions |
Answers |
Evaluation |


text:
Lotus Touch Organic Naturals™ Massage Lotion Ideal for deep tissue massage! A blend of nourishing, certified organic seed oils that create a lotion with high glide and low friction. Flax seed and olive oils feature vital essential fatty acids, jojoba oil penetrates the dermis for lasting moisture and shea butter provides a silky glide and finish. This elegant product is completely absorbed by the skin leaving it silky smooth. It is water dispersible and contains no nut oils, parabens or glycols. Available in 8oz squeeze bottle, 1/2 gal and 1 gal container. Pure Ingredients Organic Flax Seed Oil - Contains appreciable amounts of essential fatty acids which are vital for healthy skin. Organic Jojoba Oil - Light, highly penetrative oil. Good for all skin types. Non-comedogenic. Organic Olive Oil - A moisturizing oil that is high in essential fatty acids. Organic Shea Butter - Excellent for soothing, protecting and moisturizing the skin. Has properties known to regenerate cells and capillary circulation.
My clients like this silky formula, unfortunately it makes my hands itch. I thought I was buying Organic. Oops, I assumed that since it was coming from "organic Naturals" that it was organic, or at least natural. I have made this lotion into "gift" lotions with essential oils for my clients and in gift baskets. I try to use ONLY organic products in my massage practice.
Doesn't retain glide because it soaks in too quickly. Have to use more lotion and it exfoliates pretty quickly.
This is my favorite lotion because no shower is required or towel to clean it off. Been using it for many years.
I love working with this product! My clients love it b/c its not greasy and leaves them feeling moisturized, rather than slimy. It is great for my hands b/c it leaves them feeling soft & moisturized even after I wash them after services. I only wish you could buy it in a bigger size than the 1 Gallon. With my business I have found I am re-ordering more frequently than I am used too. Love the product though!
I have been using this for over a year. I have tried other products in there line but have founf this one to be the best by far!!
The Occupational Safety and Health Administration requires that MSDS be available to employees for potentially harmful substances handled in the workplace under the Hazard Communication regulation.
Lotus Touch Organic Naturals Massage Lotion MSDS

subset: commoncrawl


text:
7 Ways to Flirt In a Web 2.0 World
5. Play hard to get: The Internet is all around us. We have it at work, at home and even on our phones. That means you're available almost 24/7 to interact online. Play hard to get! Don't respond right away, or don't respond all day. The person on the other end will be checking their chat or email constantly to see if you've responded, and once you finally do, you'll have them hooked.
6. Compliments: Handing out compliments is an art. Over the web, you have to compliment each other without sounding creepy, and say something that will receive a positive response. You're probably not going to be the first guy or girl to tell them they're beautiful or handsome, so be creative. A well thought out and personalized compliment will lead to infatuation and potentially more conversation.
7. Confidence: Being confident without being cocky is a turn on. We all want someone who is sure of who they are and is always willing to be themselves in any situation. Don't pretend to be someone else, because more than likely your date will be able to see through that when you meet in person. If you can exude as much confidence as you do online in person, you just might seal the deal.
What steps did you take to meet your partner while online dating? Share your comments below.


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For students who graduated from college or university this spring, paying back students loans is a pending reality as interest is accumulating and they're halfway through the six-month no-payment grace period. Put debt in perspective However, Canada Student Loans, like any loan, must be repaid. Unlike traditional loans, interest only begins to accumulate after graduation and repayment is not required until six months after graduation. (Note, even if you don't graduate, you have to pay back your loan when you stop attending school.) Once your grace period is up, you'll get information from the federal and provincial governments about how much is owed and how to set up a payment schedule. TIP: Students tend to move around a lot so it's important to notify the student loan office of your most recent contact information. In most cases, that's it. You meet your monthly obligations, and you can opt at any time to make lump-sum payments, increase monthly payments or pay off your debt in its entirety.
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